uh, we left off with the philosophy of the Medical Center--the originalphilosophy of the founders of this institution. Could you tell me alittle bit about the philosophy?

ROMANO: There was a very definite uh, philosophy. It was articulated

well by Dr. Willard and uh, there was every intention to really createa Medical Center that was going in a slightly different direction andI think to understand this direction as it was defined in 1961, onehas to understand the status quo of, let's say, academic health centersand uh, I would have to say that by 1961, uh, medical centers were1:00characterized by what I might call entrepreneurship. What you had wascolleges, a hospital, uh, that seemed to be related in one cohesiveunit--one entity--but the reality is that if you look closely it was alot of little kingdoms and fiefdoms, each with very well circumscribedboundaries relating to each other and relating to each other on termsthat were set by individuals and whereas it seemed as though there wasa central administration and there was a central theme to the missionand all of that, still you had all of these strong people heading up2:00little units, doing their thing and safeguarding their interests andsafeguarding their future, et cetera. Now, unfortunately that soundsa little critical and I--I'm not comfortable with the way that--thatstatement came off, but one has to be realistic about people beingpeople being people, and when there is an opportunity for someone togain security and to look after number one, most of the times you cancount upon people taking advantage of that opportunity. Let's put itthat way. Okay?

SMOOT: Yes.

ROMANO: So let me get specific. The surgery department was interested

in the surgery department and the future of that surgery department.They uh, had responsibilities in the teaching program. They hadresponsibilities for patient care in the hospital, but unfortunately3:00it seemed as though they were--their main thrust was to generate fundsand they would generate these funds in several ways--first of all, ofcourse, by the actual patient care that they rendered, secondly, bybringing in research grants, thirdly, by being involved on a nationalscale in presenting courses, papers, being involved in all kinds oforganizations--professional organi-organizations, etcetera. As aresult of all of this, the main function of the academic health centerwas somewhat obscured because teaching suffered. You know, meanwhileback at the ranch (Smoot laughs) there were a number of students.4:00You had this responsibility to these students who came there to--tobe instructed by you, to uh, uh, to drink of the fountain. Okay?Partake--and where were you? You were on some airplane flying away,going somewhere or you were too involved with patient care. So theperspective was a little, um, skewed in favor of, um--skewed againstthe--the academic activities and Dr. Willard recognized this and Dr.Willard tried to do something which was unheard of in those days.He came on with a system whereby you got one salary. You receiveda salary from the Medical Center. You negotiated for that salary.You came with an understanding that that was your salary and thenanything else that you generated in the way of funds was put into5:00the main Medical Center fund. In other words, you weren't a privateentrepreneur. You worked for the company and whatever you did--whetheryou went out and gave a paper, whether you were a consultant, uh,patient care fees, uh, research fees from grants--all went into a fundand the Medical Center then depended on that income as part of youractivity and you were paid a certain amount and that was it. Now, thatwhole concept was intended to safeguard the primary mission, which wasteaching. Now, you've got to give Dr. Willard a lot of credit fortrying this. I don't know if anybody else brought up this point.

SMOOT: No.

ROMANO: You've interviewed a lot of the folks that were here from day

one and perhaps none of them brought it up.

SMOOT: I don't--I don't recall.

ROMANO: I bring it up because I personally was affected by this

6:00immediately. I came on in July of 1961. Okay. I had, in June, justreceived a federal grant to do a study--a two year study--of the useof television in medical and dental education. Part of that grantincluded a stipend to me. Well, I actually had to take a cut in salaryfor the first three months to make up for that money that I got fromthe grant. Now, if I had remained at the University of PennsylvaniaI would have realized that honorarium as an additional income. Soimmediately I was affected by this policy of trying again, to insurethat the primary mission was not adulterated and that uh, people wouldnot become uh, a little too enthusiastic about extracurricular andextramural activities.

University of Pennsylvania, that this was not working out well as faras--in the academic program. So I came understanding this--everybodyelse did--agreeing to it. I received a considerable increase in incomeover what I was making at Pennsylvania for instance, and I came of myown free will and they were the rules. Well, it didn't take long--ittook about two years--for the system to break down. Uh, the firstchairman of surgery is responsible for breaking the system down. Now,he came fully aware of the system and quite frankly most of us aroundhere were somewhat disconcerted that a person would come understandingthe rules and then come on and start from day one to work against8:00those rules and to try to change them and he did. He succeeded. Hesucceeded in breaking the system down.

SMOOT: Hmm.

ROMANO: And we then reverted back to being an ordinary Medical Center.

Now, I realize that this was almost an impossible task. It wasidealistic, uh, but I--I was disappointed that it only lasted twoyears. I had hoped that it would have lasted long enough at leastso that we could document the results, the impact on the teachingprogram so we would have something to go by and say, "Look, ideallyif we starting a new country in a world somewhere--(laughs)--and anew Medical Center and there wasn't already an existing system, here'sthe way you ought to do it." You ought to get people--say you want tobe an academic physician or--or dentist or whatever--come in, here'swhat you get as a--okay--and perhaps in a--in a system--in a national9:00system--in an international system--where you had this individualentrepreneurship, maybe it was unrealistic to think that this was goingto work out. You see, it created--it created an environment of thehaves and the have-nots. Just imagine how much more, uh, successfulin generating funds the surgeons were compared to the restorativedentists, the pediatricians, the psychiatrists, even the internistscouldn't match what surgery did. So Dr. Willard's concept was thateven people who were not involved in generating funds, like communitymedicine--and that's a whole story and if you haven't interviewed KurtDeuschle you should interview him. Have you interviewed him yet?

SMOOT: Not yet, no.

ROMANO: Okay, you--are you going to?

SMOOT: I hope to.

ROMANO: Okay. Well, specifically probe this particular matter. He

10:00really, I think, could give you some insights because you see, he wasa physician who was in a department--community medicine--that did notgenerate funds. They didn't do patient care. They didn't do hands onpatient care. So therefore their capacity to generate funds was nothinglike even pediatrics let alone surgery and yet Dr. Willard, who was ina sense the founder of this whole community con- uh--medicine concept,okay--recognized that these folks would be at a disadvantage, but feltthat in the system that he had defined and had--had put in place hereat this Medical Center these people would fare just as well as thesurgeons. The concept is idealistic and it's a good one and there weremany of us that were very disgruntled that in fact it didn't surviveand that Dr. Willard's leadership wasn't sufficient--and I say thiswith all kindness to a man that I respect greatly--wasn't sufficient--11:00okay--to deal with the big lions in the surgery department.

SMOOT: Hmm.

ROMANO: And they're big tigers.

SMOOT: (coughs) Apparently, if they subverted the system and--was it

just the surgery department?

ROMANO: Well, the surgery department, you know, uh, started to pick

at something that uh--then everybody else--not everybody, but otherincome--potentially income ge-generators--

SMOOT: Um-hm.

ROMANO: --uh, were very happy to go along. He got, uh, you know, he got

uh, colleagues who--who supported his uh--his approach. So uh, I--I'dsay in basic philosophy that was--that was one of the uh, main facets--main dimensions--of a philosophy that in the sense did not work. Now,the other aspect of the philosophy was that this Medical Center hadcommitted themselves--in the basic mission-- to be involved with morethan turning out manpower. Until then academic health centers were12:00involved in essentially education and research and only the patientcare required to carry on the education and the research. Well, Dr.Willard, with his department of community medicine, had envisioneda Medical Center that would have an impact on how patient care isrendered throughout the state--

SMOOT: Hmm.

ROMANO: --by virtue of first of all impacting on the health

professionals that were out there, and secondly by going into theunderserved areas and creating patient services--patient care, anduh, by first, uh sec---thirdly by, um, developing a system where youhad feedback on what was happening around the state. In other words,our outreach program was going to be an essential part of this MedicalCenter's basic mission. Now, that hadn't been done before. Again, you13:00know, you're circumscribed--you belong to a university, you're health--an academic health center, you worry about your--uh, turning out uh,your students, you worry about uh, g-g-grants and uh, doing researchand you worry about running again, the patient care required to do allof this and also to generate some income which would help the MedicalCenters to be uh, uh, financially viable. So I think there are the twothings that were the key new dimensions of uh--of this Medical Center.Now, if I say that both of these things failed then I'm implyingthat the Medical Center has been a failure and that's really not thecase because although both of these basic concepts were--first the one14:00about the remuneration uh, that came on early, in about two years andthe one later came on maybe ten years later, uh, eliminating communitymedicine. There's no community medicine department in this College ofMedicine now. It's not there. It was dismantled by the last dean anduh, he didn't do it because uh, he didn't care about our mission or hehad nefarious, you know, motives. He did it because the time simplycould not al---permit spending funds for that kind of activity.

SMOOT: Hmm.

ROMANO: And also that there was a certain resistance from the health

community in Kentucky against the Medical Center having all thisoutreach out there and try to impact on--on uh, their domain. Sothat's another factor that uh, had to be considered that as a--workingagainst this basic, uh, concept.

SMOOT: Making them look bad?

ROMANO: Well, not making them look bad, but in a sense, poking around

15:00in a territory that's mine. You know, uh, I'll take care of renderingpatient care out in the state, you take care of uh, producing manpowerand there's something to be said for that, you know. I like to lookat most situations in terms of what I call legitimate vested interests.You've heard the term vested interest, but vested interest has a badconnton--connotation. Vested interest implies, uh, a dishonest motive,a selfish motive, but when you say a legitimate vested interest I thinkthat gives it a different sound, a different uh, uh, connotation and--and uh, they're often--most situations today in our complex societyinvolve what I like to call legitimate vested interest--I have everyright to have this--this objective, to have this interest in something,I have every right to have a vested interest in whatever.

SMOOT: Um-hm.

ROMANO: It's a legitimate one, but that doesn't mean that it doesn't

conflict with your legitimate vested interest and of course, you know,16:00this is the--the--the tug and the pull of--of our society, uh, andin a sense this is what keeps the society viable. I look at it as aplus, in contrast to a stagnant society. I--I've never been to Russia,I've only read, but a society where vested interests are subserted--subverted, rather--to the state and the state says you will do this andthat's it. You know, even in the production of uh, automobiles, youlook at some of their auto---you look at their automobiles and look atours--there's no comparison because competition, again the interplayof legitimate vested interests, is the essence of progress, of vitalityand it--in the long run it helps the many.

SMOOT: Um-hm.

ROMANO: So. I look at it as a plus from any point of view, but there's

no question that--that, you know, when you look at a situation thatuh, you know, like this situation I'm referring to about uh, uh, theMedical Center trying to become involved in uh, the-the health--uh,17:00health care in the whole state. Uh, this was really uh, contrary tosome of the legitimate vested interests in the state.

SMOOT: Um-hm.

ROMANO: So that's another reason why, of course, in the long run

this didn't work out and then in the 1970's because we had a wholereevaluation of the funding of Medical Centers--that whole picturestarted to change in the middle seventies--um, there was no way tosupport that kind of a department, so we reverted back to, you know,where--where medical education was in the fifties without these kindsof things.

SMOOT: Um-hm.

ROMANO: Uh, I believe they were the two main facets of--of the Medical

Center philosophy. Oh, I could go on and on in the philosophy andhow you treat students. Let me talk a little bit about how you treatstudents.

ROMANO: Uh, one of the things that impressed me when I visited was that

uh, there was this huge area on the first floor here all devoted tostudents. They had a lounge, they had a uh--a uh, concession uh, areafor food, uh, you know, with the machines, they had not just lockber--lockers, each student had a cubicle, with a locker, with a bookshelf,with a desk, with a light, there were acres of these things all over thefirst floor here and I said, "Wow! This is some place, it really givesthe student the status that the student really deserves. It gives themthe capacity to study here, to live here, to work here, it's studentoriented." A little at a time, all these spaces were cannibalized. Asdepartments grew and they needed space the first thing they looked at19:00was the--the disenfranchise--the students-- and what could they say? Gotake some space from a department and see what happens. Okay?

SMOOT: Um-hm.

ROMANO: So a little at a time we reverted back to each student having

a locker and all of these facilities for students, that in my judgmentgave us an edge in our appeal as an institution to young people andhow unfortunate that today when we're going to be competing to getstudents, I can't take a student around and say, "Let me show you whatyou'll have if you come here. You'll have this cubicle, you'll havethis lounge, you'll have all these facilities here for you." That'sunfortunate. Now, what is particularly distressing to me personally isthat in the middle seventies I was involved in the development of the20:00Health Sciences Learning Center across the street and I was involvedwith convincing the administration that we should reconstitute some ofthese student areas and that Health Sciences Learning Center had twomain student areas--the sixth level where, if you've been there, it'sa study center and students can study in a variety of ways and I wasinvolved with the design of that. They can either sit down alone in acomfortable lounge chair. Have you been up to the sixth floor?

SMOOT: No, I haven't had a chance to go up there.

ROMANO: Oh, you can--should go up there.

SMOOT: I will.

ROMANO: It's a unique area.

SMOOT: I will.

ROMANO: Okay. Everything from my--my sitting down alone with my shoes

off in a soft chair to sitting at a table and writing or--from a bookto going to a carrel with a video cassette or a slide tape to goinginto a little room--the periphery of that large area has all theselittle conference rooms--so that I could study with a group of five,seven, eight, ten colleagues.

SMOOT: Hmm.

ROMANO: That was all designed, you see, with the student in mind. Now,

in addition to that we had a lovely student area on the second floor.21:00It was a multipurpose area. It was a large reception area with a-anarea at--at one end that could be closed off with folding doors and itserved with all comfortable chairs--I don't know if you've ever beenthrough the second floor of the Health Sciences Learning Center--that--the-the objective was to re---to--to give again to students things thatthey had initially and--and were taken away from them. In additionto serving as a student lounge areas and--and just social areas let'scall them, that second floor area also was important in--in runningmajor conferences because with the two large conference rooms there--wehave two auditoria there. You see, when you have a-a conference, youcan use that large multipurpose area for registration, for lunches,for all these kind of things. Well, just imagine how distressed I waswhen about a month ago--I uh, hadn't been there for awhile--I happenedto stop by accident when the elevator--I was going to the third floorand I stopped at the second floor and I look and there are workmen22:00putting partitions in that area. They've cannibalized it. Now, againthis is the process we went through in--in the early sixties, you see.So that was a major aspect of our philosophy. It's almost as thoughthere's a certain scheme to things and the scheme to things--the schemeof things involves the haves, the have-nots, the powerful, the littleless powerful and the-the helpless. Okay, there's all ranges of powerand it just seems that no matter what--and I'm not a cynic, I'm mosttimes an optimist in--in almost everything in life--but you've got tobe a realist and you've got to recognize that there're the facts andit seems as though you could take society or any element of societyand it's all made out of rubber and you can take a piece of it and you23:00can work hard to reshape it and you make all this effort to reshape aMedical Center with all the basic concepts being different--just as wedid in the sixties--and all these people who are interested--I picturethem--I have this vision of this big structure and all these peopleare pushing in a little piece of it so that it looks different. Froma distance you look at it and, by golly, it does, it looks different.They've reshaped it and then one person relaxes and it bulges outagain a little bit here and another person relaxes out up there and itbulges out a little bit there and then that person gets a little tiredand (Smoot laughs)--and for whatever reason--and before you know iteverybody kind of gets lax and the whole thing--lulilili-- goes backinto its original shape again.

SMOOT: Hmm.

ROMANO: That seems to me like the way things happen because that's what

happened to this Medical Center. You know, there's some of us thatcame here full of idealism, believing in fact that we were on the vergeof a--of a new model of academic edu---uh health science in education.So, now again, I'm not--I don't want to come off being bitter about24:00this thing or being sad or disappointed. I'm merely stating thefacts as they are. I believe--and I'm not sure anybody else has saidthis and I'm going to say itcandidly and straight out--I believe it'sremarkable that in a fifty--fiftieth rate state--and in so many thingswe're a fiftieth rate state--we have about a twenty-fifth rate MedicalCenter. That's remarkable-- as it is today-we started off being a--atenth rated. We were in the first ten as far as uh--from all pointsof view. We've slipped, we've gone to be twenty-five, but look atthe other public institutions of this state and compare this academichealth center with the other public institutions and I believe we're25:00much higher. We're--we're--it's amazing that we can survive and existbecause, you know, you--your environment impacts on--on what you are.So uh, I think that Dr. Willard and the people that founded thisMedical Center should have a lot of satisfaction in recognizing thefact that maybe all of their hopes and aspirations and expectations didnot materialize, but having started at such a high level we still todayare better off than if Dr. Willard wasn't a visionary and had juststarted an ordinary health center. We would be at a level with theother edu---public education facets of this state.

SMOOT: Hmm. (coughs) So then, you would see this as a residual effect

uh, of the original ideas and philosophies of the--

ROMANO: Oh, I--of course.

SMOOT: All right.

ROMANO: Of course. Um, I think these people were visionaries. I think

26:00things being what they are, they didn't achieve all of their goals, buthaving aimed high it's the old story--you gotta hit higher than if youhad just aimed, you know, anywhere.

SMOOT: How's the d---the College of Dentistry fit in, in comparison with

the other colleges within the Medical Center?

ROMANO: Well, I'm biased. I'm very biased. See, again, in a state

whose ed--public education system--at every level--is kind of near thebottom nationally--we started off in the sixties with a Medical Centerthat was near the top. The first quarter, you know, first 25 percentfrom almost any assessment we-we ranked--as a Medical Center. Now, theCollege of Medicine may have ranked fifteen , the College of Dentistryranked two, three, four, five, you know. It would--depending on whichassessment you take as valid we were one of the leading dental schools27:00in the United States in the early sixties when we were first developed.Now, I'm biased enough--and this is really a very biased opinion--tothink that today we still have the residual effect of being a littlebit better. It isn't--um, I don't have any valid reason for sayingthat on a national ranking we may rank a little higher than our Collegeof Medicine or Nursing or--uh, I won't say our College of Pharmacy. Iwould have to acknowledge that the--probably the College of Pharmacyis nationally ranked higher than any of the other colleges in this uh,Medical Center, um, but it's a very biased opinion I have about theCollege of Dentistry.

SMOOT: Hmm. How about with the University of Louisville?

ROMANO: Well, again I have to be biased. I have to be biased and

yet--you see, there's three things you have to teach students in28:00a--in dental education: knowledge--you have to impart, I like theterm impart--knowledge, skills, and attitudes. Now, national boardexaminations, state board examinations only evaluate knowledge andskill. Attitudes are not evaluated except on a long-term basis. Ibelieve that the basic philosophy of this school--which is still intactafter twenty years--uh, teaching students or imparting to students anattitude of professionalism, of being broad in their thinking, of being29:00flexible, of accepting the techniques, for instance, that we teachas a good technique and not the only technique, that there are othertechniques, we can't teach you all those techniques. It's the firstthing I say to the first year students. So what is our responsibility?Our responsibility is to pick one of the good ones and to teach you agood technique as a beginning, but beyond teaching you a good techniquewe have to instill in you the judgment that permits you, throughoutthe rest of your professional life, to look at all the techniques andto discard those that you don't feel are in the best interest of thatpatient and to change the ones that you already know for a new oneonly after you use your judgment and I believe when it comes to--tothose kinds of things, I think our school is uh--is unparalleled quitefrankly.

SMOOT: Um-hm.

ROMANO: Again, a very biased opinion.

SMOOT: Most of the students in the College of Dentistry have been from

studies here in the College of Dentistry? After all, uh, it's wellknown that Kentucky does, uh, not rate well in comparison withother states in public education and so forth. Uh, how have theyseemingly been prepared and are they of--adequately prepared fordental education? Are they uh--do they have the background necessaryor is there a little bit [microphone interference] more difficulty incomparison with students from other states?

ROMANO: Well, this was easy for me to answer, uh, in 1961, when I had

just come from the University of Pennsylvania and, you know, the daybefore I came here I was involved with the teaching program at theUniversity of Pennsylvania and I was prepared to make a comparison.I was competent to make a comparison at that point, but remember31:00that in our first class we chose twenty-five people out of some sixhundred applicants. We chose literally the cream of the crop. Sotherefore, I was very pleased at the quality of student, the way theywere able to neg-negotiate the curriculum compared to the Universityof Pennsylvania, but over the years two things have happened. Firstof all the number of applicants versus the number of spaces we have hasmarkedly changed. For forty-five places last year, we had somethinglike eighty-some out of state appl---in state applicants.

SMOOT: Hmm.

ROMANO: Okay?

SMOOT: Um-hm.

ROMANO: So that's a vast change and secondly, after twenty-five years-

-it's twenty-four years now--I don't know whether I'm really capable of32:00remembering--of being able to compare how they fare compared to otherstates or other students or the University of Pennsylvania. You--tha---I think it's understandable that that's uh, you know, that's theway it is. Uh, I--I've always been, um, well, I'm not going--I'lluse the word empathetic to what young students, uh, have to deal within a curriculum like ours--a difficult challenge. It--those of usthat--that end up being good teachers or that are good teachers, thoseof us that are good teachers are good teachers in my judgment becausewe always kind of maintain this empathy, this understanding of whatthe student is going through. Um, when I was a department chairmanand we'd take a new person onto our faculty, this person would say,you know, I--I--aren't you going to teach me how to teach, I've nevertaught before. Often we'd take somebody out of practice and uh, Iwould say, well, I--I--I know how you feel, but you have had a great33:00deal of experience in the student-teacher relationship because you'vebeen a student for so many years and if you keep that in mind, ifyou always keep in mind how you felt as a student, it's going to haveto be a help in being a teacher. I do that with--with uh, patientrelationship also. I tell young practitioners, as a clinician you havea great deal of experience in the doctor-patient relationship becauseyou were a patient so many times, uh, and I--I think that's the keytoward devel---towards maintaining a--a good attitude--an attitudethat's--that's productive in teaching--uh, toward your students. Soum, I'm very biased for the young people that we have here. Um, oneof the reasons that I'm pleased that I'm back in teaching after so34:00many years, uh, being away from it--eighteen years I was away fromteaching--is because of um, what being with these young people doesto me as a person and uh, (laughs) at my age--in--in my early sixtiesnow--I'm-I'm determined to try to keep a--perhaps a more youthfulattitude towards life and towards things in general and uh, I thinkbeing here with--with young people is a--is a big help in this--in thisuh, respect and uh--I like teaching. I like being involved with youngpeople. I like the importance that I feel, um, in having an impacton their lives, having an opportunity to have an impact. Too manyteachers lose sight of that--of the tremendous opportunity that youhave and it's a--obviously a big responsibility, but you know, you can35:00teach all the techniques you want and all the knowledge that you wantand all the skills that you want--if you don't impart to that studenta sense of professionalism then uh, you've lost the opportunity, you'vemissed it. Uh, one of my favorite little, kind of, uh, approaches thatI use with students is uh, you have to resist the temptation to kindof be one of the boys in the neighborhood, in your community, in yourpractice. When there's something wrong with my health--whether it'sa toothache or a toe-ache or a headache or I need a new heart--Uh, Idon't want an ordinary person to treat me. If I had the opportunityI'd like to have God taking care of me. That's not possible, sotherefore, I have to accept a human and I don't want somebody wholooks like my buddy (Smoot laughs) or the guy next door. You've got36:00to create an image of being somebody just a little bit better, just alittle bit special and then you're going to instill the confidence thatpatient needs and that confidence is critical to how that patient carecomes out, how--what impact you have on--on--on their health problem.I think it's--it's a logical, straightforward approach to what, youknow, to the attitude we're trying to impart to our students here andmost of us on the faculty have that kind of an approach. Uh, you know,each of us do it in our own way and that's what's beautiful about it.I may say it in that way, somebody else may say it in another way,somebody else may not say it at all. They have the capacity of beingthe model and not having to say it. That's the best way to do it. Youknow, sometimes I say to myself, uh, saying it is being redundant--beit. Well, I try to be it, most of us do, but still I want to makesure, 'cause I've got one pass at them. Four years, then they're outon their own, developing on their own. I tell people when they're37:00about to graduate, the only thing that piece of paper does--it givesyou the opp--the opportunity now, the responsibility of furthering youreducation on your own. You're re-responsible for your development. Wewere responsible to some degree during your stay here at school.

SMOOT: Hmm. Doesn't that necessitate; however, uh, striking a careful

balance? Um, a lot of people look at the--people in the medicalprofessions and say, oh, this person has a God complex. Uh, they're--they see themselves as--as the ancient priest looking down upon themasses and imparting certain bits and pieces of knowledge and healingwhen--when necessary and uh, p--placing themselves on a pedestal. Uh,you see--and I'm sure--

ROMANO: Of course.

SMOOT: --you've heard this uh, many times. Isn't there a balance--

ROMANO: Oh, of course.

SMOOT: --that you have to really strike at?

ROMANO: Isn't there a balance in everything in life?

SMOOT: Sure.

ROMANO: I was sitting with my children (Smoot laughs) many years ago and

uh, they were all young and sitting around a table and we were eating38:00dinner and uh, one of them said, "What's for desert tonight, Mom?" andMom said, "Ice cream" and they all said, "Oh, great!" and I said, "Tellyou what, guys, you guys are really crazy about ice cream, aren't you?Well, I'll tell you--I'll tell you what we're going to do. We're goingto make life simple for Mom, she won't have to cook any more. From nowon, everyday, breakfast, lunch and dinner the only thing you're goingto eat is ice cream." (Smoot laughs) "What? You mean nothing else?"Well, of course you know what the result of that was.

SMOOT: Um-hm.

ROMANO: They wouldn't buy that. Everything is a balance--sure it's a

balance, but if you're going to err, best you should err on the sideof being a little more like God than being a little more like a person.Listen, you may not have ever had any life threatening situations yet,young man (Smoot laughs). I'm talking to you, okay?

SMOOT: Yes.

ROMANO: But I had a sledgehammer in my chest once.

SMOOT: Hmm.

ROMANO: It wasn't a heart attack, thank God, it was not an infarction.

It was a-a myocardial spasm--

SMOOT: Um-hm.

ROMANO: --but I thought it was a heart attack and when they rushed me

39:00into that emergency room, I wanted God to be there! No way could thatperson overdo this God complex. I want somebody with confidence, andcapability, somebody I look up to. I'm down, I'm dependent. You can--you know, you can overdo it, but uh, I'm not concerned about that.

SMOOT: Um-hm.

ROMANO: We've--the tendency has been to go in the other direction, you

know, "Oh, call me Joe." Well, you know, in my office I'm not goingto say call me "Doctor" if you call me Michael, but if you give me achoice I'm going to say, you know, in the office I like to maintainin front of my staff, et cetera, a professional relationship. I thinkit's in a--in your best interest uh--or say something like that. Okay.But I don't have to worry about that because if you look like you'reDr. Romano, you're Dr. Romano and you--you--you each--see the thing40:00that's changed over the years in--in this facet of educating studentsis that there was a time when we tried to put them all in one mold.Everybody had to wear a white shirt with a dark tie and everybody hadto have dark pants and dark shoes and shined shoes and the shoes had tobe leather shoes. Okay. We tried to put them in a mold. We gave--wemade no room for individuality--

SMOOT: Hmm.

ROMANO: --and now I say to students, "Hey, I'll tell you what you need

to concentrate on--be well groomed, but don't lose your individuality."That's the key, see.

[Pause in recording.]

SMOOT: I'm--like to ask you about the relationship, uh, between the

physicians, dentists in the Medical Center and the people in thecommunity. Uh, we've been talking about the attitudes imparted to thestudents and student-faculty relationships and so forth. What about41:00the attitudes of the practitioner and the medical community outside ofthe Medical Center? How--

little uh, perhaps, but I've always found it possible to establishand maintain a good relationship with my colleagues in the dentalcommunity. Uh, I go to the dental society and I feel very comfortable.I've always felt comfortable, but on the other hand that's still aresult of the 1960's and the 1970's. See, now we're in the 1980'sand this whole business of town-gown is the--the--whatever differences42:00there have been, are becoming exacerbated and I'm going to ask you, doyou have any idea now, why they're exacerbated in the 1980's?

SMOOT: Are there too many dentists--too much competition, costs

involved, uh?

ROMANO: That's it. Okay. So now let's talk about, again if we've

covered the matter of students et cetera, let's talk about the milieuof the 1980's.

SMOOT: Please.

ROMANO: Okay. Um, I need to know from you whether you've heard

this term or not, because I suspect that not too many people havearticulated it quite this way. I have felt for several years now thatwe're into what I call an age where we're seeing the commercializationof health care--the commercialization of health care.43:00

SMOOT: I've heard that used in a variety of ways.

ROMANO: Okay.

SMOOT: How do you mean it?

ROMANO: Well, I mean it that there was always a difference between

the health professions and commerce and industry. There was alwaysa difference. We often were compared and yet whenever anybody triedto look at it, the basic motivation, the basic structure, the basicthrusts of commerce and industry and the basic thrusts and motivationsof-of health care industry--you didn't even call it an industry, tenyears ago if you called it an industry people raised their eyebrows,particularly people in the health care field--but if you comparedthem both, there was always a uh--a comfortable difference. Okay--andthe difference could be de-defined very simply--that in the world of44:00commerce and industry, the whole beat was the dollar bill. The heartbeat was earning money.

SMOOT: Profit.

ROMANO: Okay. And in health care industry or the health care fields

as it was called, it was helping people. Now, in 1969, I left thewarm womb of academic dentistry and I was recruited as president ofa company and I went to Madison Avenue. I had a big office suiteand there I was sitting in this big office with thirty-seven peopleas a staff, president of a big company. For the first two days Ifelt great. I accepted the offer where they--they made me an offerI couldn't refuse. They doubled my salary, all kinds of perks andbenefits. The company was one of the main investors with Frank45:00Sinatra, he uh, recruited me by flying to New Orleans and uh, pickingme up in his Lear jet, called the Christina and flying me to New Yorkand by the time I got there, he sold me. I left all those years, 1967--I started in 1950--I left seventeen years of academic life in dentaleducation. I had reached a point of becoming an associate dean at aschool. Uh, most likely, had I remained in dental education I mighthave gone on to be a dean and I, you know, I was fairly satisfied withwhat I was doing and very happy--very happy and I was seduced into theworld of commerce and industry and two days I was happy and the thirdday I realized, what have I done? I'm not used to this kind of heartbeat. It's like a heart transplant. I've got a different beat. I'mnot--I'm not tuned into this profit--money--everything, every decision,everything you deal with has to be resolved in terms of what's mostprofitable, how much money is it going to cost, how much money is it46:00going to make us and quite frankly, although I worked hard and--andfulfilled my two year contract, I was very unhappy and very much out ofmy element. I-I'm mentioning this because I have had the experience,okay, in comparing the two worlds and there was a difference--vastdifference. Well, what's happened now? Well, that difference isn'tas great as it used to be because now in health care we have seencommercial interests loom very large and very important aspects of thehealth care and I'll say now, today industry. The for-profit hospitalsare in the forefront of this change. Uh, when one thinks of thestatistics it's staggering. Ten years ago the for-profit hospitals had47:00something like four percent of the beds. Today they have 27 percentof the beds. It's predicted that by 1990, they'll have 50 percent ofthe beds and by the year 2000 they may have 80 percent of the beds.Now, that's major. That's profound. That's got to have an impacton everything that happens in the health center--this academic healthcenter. In addition, there are two factors in my judgment that have--are lead---have led to the commercialization of health care becausewe--we are a commercial enterprise at this point. I defy anybody totry to give a case against that statement I made. We are a commercialenterprise. We have to say, "No, I can't treat you, you're going todie, 'cause there isn't the money. You don't have the money and you48:00don't have insurance. Oh, I might give you something to help yoursuffering a little bit, but this treatment that will cure you is tooexpensive and you don't have the money and I can't afford to give it toyou." That's where we are. That's not good for a society like ours--asociety supposedly that's based on humanism. All right. That's wherewe are. Now, how did we get there and where are we going? Well, wegot there because first of all commercial interest saw that there wasbucks to be made in health care and even at a time in the sixties whenthe established system of hospitals--community hospitals, governmentoperated hospitals, academic institution operated hospitals--was still49:00sound and viable financially, they saw an opportunity to get in thereand make some bucks and there were people sitting down night and dayeverywhere in the world trying to figure out how to make bucks. Okay.So the advent, the--the--the--of--of the--the proprietary hospitals--the for-profit hospitals--is a factor that's led us to where we are.And there's another factor--the federal government--with all goodintentions, decided that if people needed health care they were goingto get it, and Medicaid and Medicare came into being in the sixties.With all good intentions, but what did that do? It created a systemwhereby you just do whatever has to be done and whatever it costs, it50:00costs, big Sam's going to pay. So we had this influx of the billionsof dollars into our health care system and it's spiraled the costs. Ifyou look at the cost of living increase in the last--uh, '65 to '78, Idid a study--'65 to '78 is twenty-three years, is--is--uh, '65 to '78.It's thirteen years. During that thirteen years there was somethinglike a 90 percent increase in the cost of living. Health care went upeleven hundred percent--staggering. Okay, so when you hear that healthcare costs have gone out of sight, you know, that--that statistic thereblows you away. You know, you had no idea that it--that there was thatmuch of a difference in the cost of living in--okay--uh, I did a studyin 1969, took a sabbatical and I did a study whereby I studied the51:00impact of the federal government on health care compared to air travel.Now, immediately when I talk about this to anybody the first questionin your mind is, what do you mean air travel? You're comparing applesand uh--and pork chops (Smoot laughs), okay?

SMOOT: Yeah.

ROMANO: But you're not, you're comparing apples and pears because the

reality is that of all the endeavors in our society you can make themost valid comparison between health care and air travel. Both ofthem deal with the service--a human service. Both of them are manpowerintensive and the manpower is striated from the highly skilled to thehighly unskilled. Somebody's got to clean out those airplanes and the-52:00-the toilets in the airplanes. Okay--and the same thing with hospitals.Okay, so from highly skilled to highly unskilled--thirdly, both ofthem are technology intensive. Fourthly, both of them depend on thefederal government or they wouldn't be there; and lastly, both ofthem deal with life and death--air travel on a minute-to-minute basis,health care on a day-to-day basis--a valid comparison. Okay. Now,when I looked into the increase in costs in 1978, when I was preparingfor the study, uh, I found that if you take twenty-eight things thatpeople buy--from, you know, food, clothing, housing, transportation-53:00-um, and you compare the increase in that period of thirteen years, atthe very top of the list is telephone service. The increase was verysmall compared to the cost of living increase. The bottom of the listwas health care--out of twenty-seven, twenty-eight things. Second onthe list was air travel. Air travel--the cost of air travel--increasedless than the cost of living in that thirteen-year period and inaddition to the cost being contained and controlled very effectively,the quality of the service was increased immen-immensely. In 1965, togo from New York to Los Angeles it took you seven hours in a propeller54:00airplane and you vibrated all the way. In 1978, you could go jet inthree and a half hours. So look what they accomplished. It--it'sbeen amazing and I was so impressed with what they accomplished thatI said, I've got to look into it and I said, the greatest factor inboth instances has been the relationship with the federal governmentso; therefore, let me look into it. What did the federal governmentdo in health care that they didn't do in air travel or vice versa?What--what--what's been the difference and the results were--werequite interesting. The results--I can give you the six-month studyresults in uh, three minutes. The government supports both of thoseactivities. It subsidizes them, but it subsidizes them in a markedlydifferent way. In the case of air travel, the subsidy is given in a55:00way where it cannot be abused by the provider of the care. They havethe whole air control system. If that was added to the price of yourticket--that air control system--it would cost you a mint. It would--it would quadruple the cost of the ticket if the airlines had to pay forthe air control system. It's all paid by Uncle Sam. Can the airlinesabuse that? Can they have more air control than they need? Becausethe Federal government's paying, let's have seventeen people here atthe tower instead of five people. There's no way you--you abuse that.They build airports--they support the building of airports.

SMOOT: Um-hm.

ROMANO: They support research and development--mostly for military--

okay. They give you weather data. All things that do not allow theprovider or the consumer to abuse the government subsidy and therefore56:00the costs have been controlled and the quality of the service has beenimproved. Remarkable--no abuses, very little if any abuses. Now, howdid they do it with health care? They gave the money to the--to theprovider at his or her terms. Okay. You go and you get the care andthen whatever you say it costs for the care, the government provides--direct payment to the consumer and to the provider. Now, well of coursethere was abuse--with no controls. That's a, a very interesting pointhere, you know, see that uh--it made the difference. So what did I saynow were the factors that created the commercialization of health care?First one was the for-profit people coming into the field. The second57:00one was Uncle Sam made it very profitable to be in the health carefield by the way Uncle Sam supported--the government supported--healthcare. Okay. The third thing that had a fact--had uh, an impact is, ofcourse, the advent of technology. You're talking about now, costs thatare out of sight for certain kinds of treatment. Incidentally, sometimeyou and I--off the--off the record--may talk about what we need to doto offset all of this. How can we still--the government still supportshealth care and not have the abuses? That was part of my study also.

SMOOT: I'd like to do that.

ROMANO: Yeah. So these are all the factors. Okay, the technology

that created the commercialization of health care and today thisMedical Center has to look at itself as though it's a--it's a--it's58:00an industry, it's a business and what we do, everything we do has tobe equated to dollars and cents. How unfortunate and yet, we neededit--we needed it. We got a little too fat and sassy and comfortableand greedy, and competition, in the final analysis, is the best wayto purify a system. Now, we're going to see a pendulum effect. We'regoing to swing from the humanism to the commercialism, but when we haveenough of the commercialism, when enough people are disturbed at thingslike--I just saw on television in the last week or so on the morning59:00show--about people being let out of the hospital before they wereready to be let out and dying. Okay. Now, just imagine, the mediais on to this now. What a beautiful system to have in this country.When you talk negative about the media, that is so stupid. Look whata beautiful system we have. Watergate would've never come to whereit was if it wasn't for the media. Even the president of the UnitedStates could--can't really get away with murder, in a sense. So we'regoing to see the commercialization of health care get worse and worseor better and better, however you look at it, whichever side of the coinyou want to look at, but more intense, more of a factor and then we'regoing to realize that we have ruined a good system and we're going toturn it back because it's an essential system. You have to have it.You know, you could almost have--you can--you can almost tolerate aneducational system that isn't that good. Okay. You can tolerate onethat has deficiencies. How long have we known in Kentucky that we're60:00at the bottom of the heap? You know, one guy got up and said--at somemeeting last week--won't be long now that even Puerto Rico is going topass us by (Smoot laughs). That hurts--okay. How long can we toleratethis? We're tolerating it, but when it comes to the health care system--hey, that's your little skin, buddy, and my little skin. Okay. Themotivation here not to tolerate and to close your eyes to a systemthat's faltering is intense, so I'm not worried. It's going to getworse before it gets better, but it's going to get better eventually.Eventually we're going to go back to a system--we're going to--we'regoing to reshape the system. We're going to develop it--redevelopit--slowly change it back to a humanistic technological system. That'sthe answer. If we were good enough to go to the moon and that--that'sawesome, but what's even more awesome than getting there was seeing61:00the first step on that moon instantaneously from there to here onearth. That--well--that blew my mind. If we are good enough to dothat, we're going to be good enough to--to get the best of technologyand help it in saving, uh, human lives and prolonging lives and uh,minimizing suffering and uh--and still do it with the--the appropriateamount of humanistic, uh, motivation and feeling in-in health care.I'm--I'm an optimist about this whole matter.

SMOOT: It almost seems contradictory, doesn't it, the--

ROMANO: It does.

SMOOT: Are there any other things you'd like to discuss? Uh, any other,

uh, matters you would like to address this morning?

ROMANO: Well, I want to talk a little bit about academic health centers

62:00as a last point--the--the real big, broad picture. If one wants tounderstand the-the future, uh, one of the things that helps you ofcourse is to kind of look at the past and if you can define some-somebasic trends, concepts in the past and they're really basic, most oftenthey will apply to the future and it'll help you in extrapolating thepresent to the future. Now, if we go back twenty-five years--let'sgo back forty-five years--we had medical schools. Most of them werejust free standing, privately owned institutions and as you know,through the efforts of a number of people, um, we saw that they becamepart of universities and the--the academics, uh, in medical education63:00became part of the academic system and it wasn't and then as partof--of universities, medical schools needed hospitals and they wouldhave arrangements with community hospitals and most of them were onthat basis twenty-five years ago, but it was not easy because theycouldn't control the program in that hospital so that it would be whatthey needed to teach. In other words, the type of patients, the typeof systems that you create in hospitals, um, weren't really the onesthat the academicians felt were in the best interests of the teachingprogram, so we went through a period where medical schools started tobuild hospitals as part of universities. Then if they were going tobuild a hospital, well, we ought to have a College of Nursing and then,well, there is a dental school here on this campus also. It's at theother side of the campus, but we do have a dental school here. Well,64:00let's put it all together then. It needs a new building, it's beenthere for fifty years, so twenty-five years ago we saw the evolutionof Medical Centers--academic Medical Centers. Well, in recent yearsyou've seen this Medical Center kind of differentiate into a healthsciences learning center, a cancer resear-research center and justfrom a practical point of view of mouthing this, you know--the cancercenter at the University of Kentucky Medical Center--you see, we'rerunning into a little problem here, but there's more to it than that.At this University Medical Center, until ten years ago, all of theunits of this Medical Center were governed by the university. Howinteresting that the Cancer Center is not governed by the university,65:00it's a separate entity, has its own board, it has its own foundation.The university gave it space--ground--they raised the money for thebuilding. Sure, it's related to the Medical Center programmatically,but when it comes to the way it's governed, it's--it's an individuallygoverned operation that's part of this Medical Center. Let's go toLouisville. Louisville, in their thrust toward what I call the me too'it--Me tooism, they had to have a university hospital. Oh, of coursein the seventies when they became part of the state system--well, U.K.has a university hospital, we have to have one too. Me too! Me too!And they're pretty powerful there in Louisville. Don't underestimatethe power of the Louisville axis and they had a university hospital,but it cost so much to build it--you know, they started off thinkingthey were going to build a hospital for forty thousand--forty million66:00dollars. They ended up spending a hundred and twenty-five milliondollars. That's a slight overrun. (Smoot laughs) By the time theybuilt it, the funding of health science education was starting to hurtand they weren't going to be able to afford to run it. They didn'thave the money to run it and what did they do? They proposed--and atfirst it sounded out--outrageous--that they give it to Humana and haveHumana run it for them, with all the programmatic, you know, tie-upsthat you needed. Well, I for one said, oh, that'll never fly. Howare you going to have something built by public funds, belongs to theuniversity, is on university ground and you're going to give it toHumana? Well, the arrangement is going to be that they're going to payrent--no way! Humana runs it. So there you have now, a health sciencescenter with a hospital--the major element--with governance of its own.67:00Now, this whole matter of having health related institutions in onephysical environment, but each with their own governance is not new.If you ever get to Houston--have you been to Houston?

SMOOT: No, I haven't.

ROMANO: If you're near Houston, go to Houston. If you're interested in

medical education, if you're interested in health care--go to Houston.Twenty-five years ago, right after World War II--forty years ago--inthe late forties, at one point there were two medical schools and threehospitals that were going to rebuild and some bright visionary got theidea, well, why don't we all rebuild new buildings in the--in the samearea? We'll go to the outskirts of town, buy cheap ground and all buildand this--we can help each other. We can interrelate in so many ways.We can have a symbiotic relationship. It sounded great. There are--there is now literally three square miles with sixty some buildings of68:00all kinds. There are five medical schools all in one area. It'll blowyour mind if you see this huge area on the edge of Houston--that's theHouston Medical Complex--and that's the term. Health centers--academichealth centers--are going to be called academic health complexes.We're now a complex. That's the next generation of word. You may nothave heard that from anybody, but that's where we are.

within this complex there's a cancer center, there's a burn center,there's a medical school, there's an academic health center and we'regoing to see more and more facilities related to health build here.69:00Our hospital may be turned over to proprietary--I wouldn't doubt ifHumana owns it ten years from now--wouldn't doubt that at all. So,that's where I see the evolution--okay--from where we were, to wherewe are, to where we're going. For all good reasons, health facilitiesneed to be close to each other and for all practical reasons--there'sno reason why they all have to have the same governance. They haveenough in common, they need each other. Being close to each other isa great help to all of them--to all parties involved--and you're goingto see more and more of this. Occur--it's occurring here and we'regoing to enter--we are now entering the era of the commercialization ofhealth care characterized by health complexes.70:00